Care Continuity

A consumer’s health may be compromised if he or she is forced to switch service providers without adequate coordination. The risk of adverse health consequences is particularly great when a consumer first enters a managed care system. To prevent problems during such a transition, it is best to allow the consumer to continue to receive services from a current provider for many months, even if that provider is not part of the managed care organization’s (MCO’s) network.

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For community-based LTSS, MCO must continue care for up to six months, or until MCO completes assessment and issues new authorization: Texas a

For LTSS, MCO must continue services for up to 60 days, or until other services are authorized under new assessment and care plan: Florida b, New Mexico c

For HCBS, MCO must continue services for at least 30 days, or until other services are authorized under new assessment and care plan: Tennessee d

MCO must continue previously-authorized services for at least 90 days, or until other services are authorized under new assessment and care plan: Hawaii e

For nursing facility services being provided by a non-contract facility, MCO must cover care in that facility for at least 30 days, until consumer can be reasonably transferred to a contracting facility: Tennessee f

When consumer resides in non-contracting facility, MCO must give at least seven days advance written notice advising consumer of need to move to contracting facility, although MCO must continue to pay for care at contracting facility to extent that consumer’s condition does not permit transfer: Arizona g

For services other than LTSS provided by a non-contract provider, MCO must continue services for at least 90 days or until consumer can be reasonably transferred to contract provider without disruption: Tennessee h

For previously-authorized acute care, MCO must continue care for up to 90 days: Texas i

MCO must honor drug refill prescriptions for new member for initial 90 days: New Mexico j